Samuel Hart*—father of two young girls, security guard at my local library, and recipient of the “employee of the month” March award—was having a heart attack. As I set up his IV and kept my gloved hand on his pulse, Samuel explained to me how he had donated his blood plasma three times within the month to help pay for his sister’s recent hospitalization. Coupled with his Type II diabetes and hypertension, Samuel’s low plasma count had sent his heart spiraling into failure. He started feeling lightheaded when his co-workers called 9-11 and my EMS team arrived.
Samuel, along with 52 million other Americans with a pre-existing condition, could lose his health insurance in the coming months—if current lawmakers pass the Trump administration’s revised plan to repeal and replace Obamacare. Despite the Republican party’s pledge to preserve an Affordable Care Act core protection for people with pre-existing conditions, a new amendment by New Jersey House Representative Tom MacArthur to the failed Trump health law proposal would allow states to opt out of this core protection, under the premise that doing so might free the insurance market to drive premium costs down. This is not the case. American citizens need to stop this plan in its tracks before it regains traction; our own wallets and health depend on it.
If states free insurance companies to underwrite those with different health statuses or segregate plans based on health risk, insurers could deny coverage or make it completely unaffordable to their sickest customers. For those people with conditions including cancer, diabetes, and asthma, costs for even the most essential services—like an ambulance ride, mammogram screen, or basic insulin injection—are out-of-pocket.
But being sick is expensive. And without insurance, a trip to the hospital is a luxury that many low- and middle- income individuals cannot afford. Sans insurance, Samuel’s heart attack would have directly cost him around $40,000 dollars by some estimates, even without accounting for indirect costs of decreased productivity and time away from work. As a part-time security guard, he makes less than $26,000 in an entire year. Supporting two daughters as a single father alongside caring for his sick sister puts unbearable financial and emotional stress on him.
Without insurance, the steep cost of care pushes sick people to forgo needed care. Last year alone, 1 in 5 adults—many of whom lacked insurance coverage—went without needed medical care due to cost.
But the financial burden of being sick doesn’t just squeeze sick people into financial and physical distress. Trumpcare’s blow to sick people risks causing an uncontrolled bleed: splitting risk-pools or in any way blocking sick people from affordable insurance poses a fiscal threat to all. When the unhealthy un-wealthy accrue the high fees of ambulances and emergency hospital procedures for late-stage illness, and then either die or declare bankruptcy, guess who picks up the tab?
That’s right—you do.
When the financial burden of being sick becomes too much for hospitals, taxpayers bear the financial burden of uncompensated care. In 2013 alone, the federal government paid $32.8 billion while states and localities paid $19.8 billion to help providers pay for uncompensated care. These costs—incurred largely by low-income individuals with pre-existing conditions—crowd out other sectors as well, including military and education spending. What’s more, hospitals must increase their prices for services and procedures across the board. In various ways, this “cost shift” is hurting Americans more. Indeed, assisting sick people with the insurance, preventive services, and early care they need could help pay for itself.
Who is Responsible?
As an emergency medical worker, I have seen many people who could have benefitted from earlier care – an elderly man with a 6-month old infection and entering septic shock, a middle-aged woman with now Stage II breast cancer because she never got a breast examination. But in many ways the ambulance is more than a medical safety net for unfortunate people. It reflects our American proclivity to protect life. We continue to fund the high cost of emergency medical services for others – so that on the day we or our children, mothers, fathers, brothers, sisters, and friends ever need it, we have the same protections.
That’s because those with pre-existing conditions don’t cause their diabetes, heart disease, hypertension, or lung cancer by sitting on a couch, eating chocolate cake, and smoking all day. Samuel works a full week and manages his hypertension with regular exercise. He pays his taxes, and he never lets his daughters miss a day of school. Like us, Samuel is a citizen who contributes to communal services and has agency in maintaining his own health.
We need to remind ourselves how many factors influencing our health are shaped by society, including our environment, housing, and workplace conditions. And all citizens contribute to these conditions, even if these factors feel like they are out of our control. Sick people’s health is in part a product of our doing; their well-being is our obligation, and, by extension, our government’s obligation. Many developed countries with universal health care, including Canada, Japan, the UK, and Switzerland, recognize this fact.
What’s the Treatment?
This is not to argue that the American medical system is without ailments, only that leaving sick people out to dry is the inappropriate remedy. The high cost of health care points to a systemic problem.
Where are these exorbitant and prohibitive health care costs coming from? Most research points to excessive spending due to over-consumption of cost-inefficient or superfluous health care services, a phenomenon called “moral hazard.” For example, a robot-assisted prostatectomy is high in demand, but it is over $1,700 more expensive than manual open surgery despite having no proven advantages. By changing our pricing incentives to reward providers for health care outcomes rather than quantity of health care services provided, we could slash the real costs that lock Americans out of the clinics.
Cutting sick people who need it most from their access to medical care is like amputating an arm for a systemic infection. Let’s stop the problem at its source.
*Columnist's note: This name is a false alias I used to de-identify my patient under my provider obligations to HIPAA.